1. Etiology and management of uterine atony Dr. Vedran Stefanovic, docent Specialist in OB/GYN, Maternal and Fetal Medicine Helsinki University Central Hospital FINLAND vedran.stefanovic@hus.fi

2. Every minute of every day a women dies from complication of pregnancy and childbirth Global maternal mortality ratio is 402/ 100 000 births, 99% in developing countries (Finland 1.6/100 000 ) Haemorrhage accounts for 30% of cases and is a leading cause of maternal death Should we be concerned? YES !!!! In UK annually 17 maternal deaths due to maternal haemorrhage and the number is increasing ! Cca 75% of ” near misses ” cases in Scotland due to haemorrhage ( 5/1000), 50% substandard care !

3. Uterine atony Uterine atony – failure of the uterus to contract adequately following delivery The most common cause of postpartum haemorrhage (PPH) A critical step in the prevention of PPH is the simultaneous contraction of myometrial fibers during and after the third stage of labour

4. Uterine contractility Our knowledge still insufficient ! Uterine contractility regulated by: -Ca ++ (nifedipine as first line medication for treatment of premature contractions -progesterone ( im injections weekly in cases of previous premature birth) -oxytocin (induction of labor, prophylactic administration immediately after second stage of labor completed, treatment of atony, -prostaglandines (misoprostol, sulprostone) From: Aguilar et al. Physiological pathways and molecular mechanisms regulating uterine contractility. Human Reproduction Update,2010

5. Uterine atony – risk factors

6. Uterine atony – management options

7. from: Ahonen J, Stefanovic V, Lassila R : Management of post-partum haemorrhage, Acta Anaesthesiologica Scandinavica, 2010

8. Uterine atony management Identifying ris factors and prevention Surgical management of lacerations Medical Surgical ( pelvic arterial ligation, uterine brace suture) Other (balloon tamponade, embolization)

9. Uterine atony Identifying risk factors Prophylactic oxytocin immediately after delivery of infant (10 IU bolus im or iv),early clamping of umbilical cord and controlled cord traction RR 0.5 Oxytocin or ergometrine? No statistical difference. Cave ergot alcaloids in patient with hypertension and HIV !

11. Uterine atony Placental retention –incidence cca 2.5% –associated with atonic bleeding –only definite treatment is MANUAL REMOVAL –usually D&C necessary  late sequelae –nitroglycerine, misoprostol, sulprostone ( 1 report with success rate of 44%)

12. success rate 39.4% Stefanovic, Paavonen, Tikkanen,Ahonen et al, Intravenous sulprostone reduces need for manual removal of placenta, submitted BJOG

13. Uterine brace sutures (Lynch)

17. Grönvall, Stefanovic, Tikkanen, Paavonen Bakri balloon tamponade for intractable massive PPH, submitted 93% final succes rate !!

18. Depertment of Angioradiology Helsinki University Central Hospital –Over 1100 interventions/year –Four angiologists –24 hrs/day availability

19. Embolization history –Nussbaum 1965, selective mesenterial angiography –Rösch 1972, superselective angiography and embolization with autologic patch –Brown 1979, the first postpartum embolization with gelatine

20. Materials GELFOAM MICROCOILS

21. Our study April 2004 – June 2007 39 patients Data colection from the hospital register 2 patients with gynaecological haemorrhage (cervical ectopic pregnancy and postoperative bleeding in the patient with ovarian cancer) 37 obstetric patients

22. 37 embolizations or baloon occlusions due to the obstetric haemorrhage a) 19 emergency embolizations - uterine atony (n=11) - cervical/vaginal rupture (n=5) - paravaginal haematoma (n=2) -placenta accreta as intrapartum finding (n=1) b) 12 prophylactic arterial baloon occlusions in the cases of suspected placenta accreta c) 4 elective occlusions and prophylactic embolisations in the cases of anticipated placenta accreta/percreta

23. Case report 28- primipara –Vaginal birth, placental partial retention – 3 D&C –Atonic bleeding, 7000 ml (Bakri balloon not still in use in our hospital)

27. After gelatine

29. The best treatment ?

30. MethodAdvantagesDisadvantages Uterine brace sutures (Lynch) 1.fast 2.suitable for atony treatment with simultaneous use of Bakri balloon 1.requires laparatomy 2.haematometra/uterin e necrosis/bowel incarceration possible Bakri Balloon tamponade 1.easy application 2.suitable for both uterine and birth canal tamponade 3.suitable during patient´s transport 4.does not require laparatomy 1.price (350 € ) Pelvic arterial ligation 1.fast 1.requires long surgical experience 2.requires laparatomy 3.embolisation often not possible afterwards Embolization 1.identifies small vessels not visible (not accessible) by surgery 1.requires facilities (often far away from the place of labor) 2.not available 24/7 in many places

31. Uterine atony Prevention Recognition Optimal treatment

32. Tänan väga! Thank U! Kiitos!